GLOBAL IMPACT REPORT 2015

Scaling-Up Excellence

Marie Stopes International

CEO INTRODUCTION

Right now, there are 225 million women worldwide who don’t want to get pregnant but aren’t using contraception. If these women represented the population of a single country, that country would be the fifth most populous in the world.

In many parts of the world, women remain unable to access safe abortion services. With no legal alternative, around 21.6 million women each year resort to unsafe methods to end a pregnancy, from counterfeit drugs peddled by ‘quack doctors’, to industrial poisons or wire coat hangers. Every day, around 22,000 women experience complications related to an unsafe abortion. One of these women dies every 11 minutes.

Shocking as these figures are, they might have been so much worse. Today, around six out of ten married women in the developing world are using contraception, giving them the power to choose whether and when they have children. In 1960, that figure was around one in ten.

With no legal alternative, around 21.6 million women each year resort to unsafe methods to end a pregnancy.”

Marie Stopes International has played a key role in driving this change, bringing our high quality family planning services to dozens of countries and on every continent. Our mission is life-changing for millions of women around the world. It ensures that they can stay healthy, but more than that, it allows them to take control of their future. It means that they can complete their education, have a career, run their own business, or spend time with the children they already have. Last year, we celebrated our 100 millionth client visit, a milestone all the more remarkable because half of these visits happened in the last five years alone.

Yet despite significant gains, unmet need for contraception is actually increasing, driven by greater awareness of contraception, lower infant mortality rates and the consequent population growth, particularly in sub-Saharan Africa. In poorer regions like west Africa, least-equipped to support the demands of an increasing population, current rates of population growth will exacerbate serious issues around nutrition, agriculture, migration, and services to support the local population.

As the largest generation of young people in history approach their reproductive years, our organisation and others working to expand access to contraception will have to redouble efforts to ensure every woman who wants to choose her family size has that choice.

The only way organisations working in our field will meet the challenges of the coming years is by being smarter about what services to provide, how to make them sustainable, and how to fund them. The stakes are high, and this cannot just be ‘business as usual’.

Marie Stopes International is an organisation with a clear unwavering mission, singularity of purpose, and unified by our determination to ensure all women and men worldwide have the power to have children when they choose. We have consistently delivered impact on a global scale, and we are ready to meet the challenges of the years ahead.

In this report we will share with you the impact that our work had in 2015, and demonstrate – using examples from our partnership of 37 countries – how our team members are actively grappling with the challenges facing our sector, and ensuring our services will benefit women and families for generations to come.

Simon Cooke
CEO, Marie Stopes International

OUR IMPACT

THE IMPACT OF OUR WORK IN 2015

Marie Stopes International provides contraception and safe abortion services to millions of women and families across the world. 2015 was the year in which we served our 100 millionth client, delivered more services, and achieved a greater health impact than ever before in a single year. It also marked the conclusion of our five-year strategy, The Power of 10.

In 2015, nearly 21 million women and their partners were using a form of contraception provided by us. We provided 3.4 million safe abortion and post-abortion care services. In the five years since 2010 the number of women we are protecting from unplanned pregnancy annually more than doubled.

6.3 million unintended pregnancies averted

18,100 maternaldeaths averted

4 million unsafeabortions averted

£258 million in direct healthcare costs averted

Lucile Umaru

I’m still in school and I’m taking contraception in the form of an implant. I wanted to be on contraception so that I could finish school without getting pregnant.”

Using metrics to measure impact is important, but our true impact is measured by how our services improve the lives of the women we serve. It’s important to remember that behind every figure on these pages are millions of individual women, each one unique. Women like Lucile.

Lucile is 17 years old, married with no children, but wants children later. She lives in Freetown, Sierra Leone, and has walked for one hour to get to her local Marie Stopes Sierra Leone centre.

“I’m still in school and I’m taking contraception in the form of an implant. I wanted to be on contraception so that I could finish school without getting pregnant. So I came to a Marie Stopes clinic about one year ago with the support of my husband. I didn’t know about the different types of contraception before coming to the clinic but I learnt what the options were and then made a decision to go on the implant.

“If I had gotten pregnant while I was at school then I wouldn’t have been able to finish my education. Since coming to the clinic I feel like I have a future.”

Lucile’s story shows the real power of contraception. It’s not simply about preventing pregnancy, but about being able to take control of her future and have the life she wants.

CONTRACEPTION, THE FOUNDATION OF DEVELOPMENT

Contraception changes lives. At Marie Stopes International, we see the impact our services have on the lives of our clients every day. We see how being able to choose the size of their family produces social and economic benefits for families, communities and economies. We believe that universal access to contraception is an essential foundation for development.

Women who control their own fertility are more likely to complete education and become financially independent. Families with the ability to choose whether and when to have children are less likely to fall into — or remain trapped in — poverty.

The Copenhagen Consensus, a group of economists which rates development policies, has estimated that every $1 invested in universal access to contraception would save countries $120 in reduced need for infrastructure and social spending. After liberalisation of trade, this makes it the second most productive investment in international development.

In sustainability terms, few areas of development can match expanding access to contraception for creating a lasting impact. Investing today can benefit women and families for generations to come.

WHO WE REACHED IN 2015

Understanding who we’re reaching is important if we’re to ensure our services are delivered in an equitable manner, to women who wouldn’t be able to access contraception because of their young age or the fact they’re living in extreme poverty. We also need to know how well our services are expanding access to contraception, to those who are not already using it, or have no other alternatives for accessing it.

Our teams work hard to understand who our clients are, and their specific needs. Knowing just a few important details about our clients in a specific region helps us to better target our services, increasing their impact and improving the experience for our clients.

HIGH IMPACT CLIENTS

We provide services to some of the world’s most marginalised and underserved communities.
One of the ways we ensure our services are reaching those in greatest need is by measuring
the proportion of clients that we define as ‘high impact’.

High impact clients are those who fall into at least one of a number of groups: women
not currently using contraception (‘adopters’), women aged 15-24, women living in extreme
poverty, and women who wouldn’t have had any other option of receiving their service if
it had not been for Marie Stopes International (‘no availability’).

how we work

RESPONDING TO A CHANGING WORLD

Globally, the number of children born per woman has been falling since the middle of the 20th century. By the end of this century, population growth will have stabilised in most regions, and in some will be declining. In sub-Saharan Africa however, numbers will continue to rise rapidly over the coming decades. The United Nations estimates that by 2050 Africa’s population will double to 2.5 billion, and will increase to 4 billion by 2100.

One of the countries likely to drive this increase is Nigeria, which has one of the world’s fastest growing populations. Based on current trends, by the middle of the century, Nigeria will have overtaken the USA to become the world’s third most populous country. By this point, it will have around 100 million women of reproductive age, the large majority of whom will want access to contraception.

At the end of 2015, just one in eight women of reproductive age in Nigeria were using modern contraception. Not only is contraceptive use extremely low, choice of contraceptives across the country is limited. In a 2013 survey, condoms were the main method used by 40% of contraceptive users, with pills and injectables together accounting for another 40%. Long acting and permanent methods made up just 12% of all modern methods used.

Marie Stopes Nigeria opened its first clinic in 2009, becoming one of the only providers of long-acting and permanent contraception in the country. In addition to its centre at Abuja, the programme uses mobile clinical outreach teams – composed of doctors, nurses, and drivers, who travel to hard to reach areas of Nigeria – to offer a range of contraceptive services to those who need them most.

We estimate that more than 10% of the women now using contraception in Nigeria were provided with their method by Marie Stopes International. We also estimate that the vast majority of our users, around 400,000, are using an implant. This indicates that we are changing patterns of contraceptive use across the country; just 2.7% of contraceptive users were estimated to be using an implant in 2013.

Long-acting and permanent methods

We believe every woman deserves choice over the best method of contraception for her, so we are committed to offering our clients the widest range of methods possible:
short-term, long-acting and permanent. However, more than 80% of our clients choose long-acting or permanent methods that will protect them from unplanned pregnancy for
anywhere from one month to the rest of their lives. Often, these methods give women more control over their own fertility than short-term methods like condoms or the
contraceptive pill.

In 2010 there were an estimated 12,000 women in Nigeria using a form of contraception provided by MSI. By the end of 2015, there were more than half a million.

DELIVERING AT SCALE, TARGETING THE UNDERSERVED

In many of the countries where we work, contraceptive prevalence is steadily increasing as more women see the benefits of being able to choose how many children they have.

Marie Stopes International is highly experienced at delivering at scale in the countries where we work. In Ghana, we provide 40% of all long-acting contraception and 40% of all safe abortion services. In Sierra Leone, 17% of all women are using contraception provided by us. Over the last five years, we provided 80% of all contraceptive implants and 75% of all tubal ligations in Bolivia.

Marie Stopes International plays a major role in the provision of long-acting and permanent methods in the Philippines. Contraceptive prevalence in the country is growing at a steady rate, just under half a percentage point annually since 2012. Almost a quarter of women of reproductive age were estimated to be using modern contraception by the end of 2015.

The estimated number of women in the Philippines using contraception provided by us has more than doubled since 2010, to around 1.8 million, around 30% of all contraceptive users in the country.

Contraceptive prevalence rate

Contraceptive prevalence is the percentage of women of reproductive age in a country who are using, or whose partner is using, at least one method of contraception. This percentage varies wildly between countries; in the UK it is 84%, in Niger just 14%. However, these figures include women using traditional
methods, such as the withdrawal method, which offer less protection than modern methods.

In 2015, the average contraceptive prevalence rate globally was 64%. The prevalence of modern methods was 57%. In nearly all of the countries where we work, it is far lower.

In 2010 there were an estimated 12,000 women in Nigeria using a form of contraception provided by MSI. By the end of 2015, there were more than half a million.

In 2010 there were an estimated 12,000 women in Nigeria using a form of contraception provided by MSI. By the end of 2015, there were more than half a million.

In 2010 there were an estimated 12,000 women in Nigeria using a form of contraception provided by MSI. By the end of 2015, there were more than half a million.

In 2010 there were an estimated 12,000 women in Nigeria using a form of contraception provided by MSI. By the end of 2015, there were more than half a million.

In 2010 there were an estimated 12,000 women in Nigeria using a form of contraception provided by MSI. By the end of 2015, there were more than half a million.

In 2010 there were an estimated 12,000 women in Nigeria using a form of contraception provided by MSI. By the end of 2015, there were more than half a million.

Lizzie banda

We don’t just stick to our job descriptions, the things you have to do according to your title. We work as a team.”

Nurse Lizzie Banda works as part of a three-person outreach team in the Muchinga province of Zambia. She is one of many Marie Stopes International team members who travel over long distances to get contraception to women who would otherwise be unable to access it. Their commitment to empowering women is a vital part of our success.

“We travel out to typical rural areas. We leave home the whole week, and it’s very tiring. The roads are bad, especially in the rainy season. It’s not an easy thing. But because of the nature of the jobs we are doing, we just have to do it despite the challenges we go through.

“There are only three of us: the driver, the team leader, and me. It’s just the three of us and a lot of work. So if you see us when we’re working, you will find the driver is also washing the instruments and other things, the team leader is maybe doing the group counselling, I will be inside providing services. We don’t just stick to our job descriptions, the things you have to do according to your title. We work as a team.

“We sleep in different places depending on the area where we are. At times we even sleep in the clinic, if we have found no other option. But that doesn’t matter. I have to work, for the people. That’s why I chose this career. And I’m very happy. I’m proud to work for my Zambian people.”

GOING WHERE OTHERS WON’T

Throughout our history, Marie Stopes International has taken our services to some of the world’s most challenging environments. Marie Stopes Afghanistan was established in 2002, the year in which the first post-Taliban Government was constituted. Despite progress in many areas since then, the country continues to experience a high level of political instability and a deteriorating security situation.

Currently, Marie Stopes Afghanistan operates 12 clinics across five provinces, through which an all-female staff offer a comprehensive range of services, including contraception and post-abortion care. The programme also employs 120 Community Health Workers, and has six mobile outreach clinics that take contraception to rural areas.

At the end of 2015, we estimate that there were 317,000 users of contraception provided by us in Afghanistan, more than 80% of whom were using long-acting and permanent methods. In the 14 years that Marie Stopes Afghanistan has been operating, the number of Afghan women choosing a modern method of contraception has increased dramatically. Currently, around one in five married women of reproductive age are using a modern method, up from one in 20 in 2003.

ADVOCATING BY DOING

Every day, in every country where we work, we see our services restricted by excessive regulation and over-medicalisation. This prevents women and girls from seeking and receiving the care and services they want.
Advocacy – and the unique way it’s done at Marie Stopes International – has never been more important for our mission.

Thanks to the commitment and courage of our country programmes we are playing an ever more active role in successfully advocating for change, even in some of the most difficult political environments. In 2015 our successes included:

— Progress made to expand the number of indications for safe abortion in Sierra Leone, Malawi, Senegal and Bolivia

— Manuals and guidelines developed and endorsed in Nigeria to implement a new policy that will enable community health workers to deliver long-acting methods of contraception.

— New post abortion care guidelines in Zimbabwe

We have always pioneered an ‘advocacy by doing’ approach. We do this in our own unique way - showing what works, pushing for change and ensuring reforms are then implemented – using our expertise so that women and girls are no longer denied the services they have a right to.

Tackling a lack of medical staff

In many regions where we work to expand access to contraception and safe abortion,
a lack of trained medical practitioners presents a major obstacle in itself. In 10 of our
country programmes, there are fewer than 10 doctors per 100,000 population.

To remove this barrier, we work with governments to recommend the introduction of
‘task sharing’, where lay and mid-level healthcare professionals are trained to provide
procedures that could previously only be provided by more senior medical staff.
Countries where women are already benefiting from the introduction of task sharing
guidelines include Nigeria, Ethiopia and Bolivia, while our research and pilot studies
are supporting potential implementation in Burkina Faso, Zambia and Afghanistan.

I knew I was breaking the law but I resorted to unsafe abortion because of pressure from my family.”

Unsafe abortion is a major issue in Zambia, and the consequences for women can be devastating. The law states that women seeking an abortion must obtain three doctors’ signatures, despite Zambia having only 1,500 doctors in a country of 16.2 million people. Having already dropped out of school to have her first child, when Naomi fell pregnant for a second time, aged 18, she felt she had no option but to take matters into her own hands.

“I knew I was breaking the law but I resorted to unsafe abortion because of pressure from my family. My parents said they would kick me out of the house unless I had an abortion. My boyfriend said that he would leave me unless I aborted. Everyone said I would amount to nothing as I would never go back to school again.

“I tried to induce an abortion three times myself. The fourth time I tried - that’s when I aborted. I had heard that there are people that help with abortions. I was told to take K70 ($10) to the place. They inserted the medicine down there in my private parts.

“That evening I felt sick, and then the pregnancy came out. The blood came out for three days. On the fourth day I was arrested, after my friend reported me to the police. I spent three days in the cells, and then I was taken to court. In February 2013, I was sentenced to two years in prison for aborting a five months old pregnancy using traditional herbs.

“I was scared to go to prison. I was worried about the number of years I would spend there. I was worried about how my child would fare since she was very young. I was really scared.

“I was released from jail on 10th June, 2015. Now that I am out of jail, I do not want to be pregnant and I will not take any chances. I’ve now had the contraceptive injection from Marie Stopes.”

FINANCING FOR THE FUTURE

Since the London Summit on Family Planning in 2012, a number of donor governments and foundations have increased their level of funding for contraception. However, many of our donors find themselves in a different place today than they were four years ago. Some are experiencing economic downturn. Others are grappling with a complex and
evolving refugee crisis. Given such pressures, it is increasingly likely that organisations that rely solely on donor funding will face funding gaps over the coming years, and will need to harness new financing opportunities to ensure we can meet the needs of the women who depend on us.

One option is domestic financing, where low- and middle-income countries take greater responsibility for investing in healthcare. Marie Stopes International has always had the
long-term vision that we will integrate with domestic financing as health systems develop. In the UK, where we opened our first ever clinic, we work on more than 70 National Health
Service contracts, funded by the government. This funding represents 84% of Marie Stopes UK’s income, which means we can serve the vast majority of our clients free of charge.
We know we can emulate this model in the other countries where we work, driven by the global movement towards universal health coverage.

tHE ROAD TO 2020

In January 2016, we launched our new five year strategy, Scaling-Up Excellence – Universal access, one woman at a time. It challenges us to go further, to reach more women with services than ever before. It also challenges us to refine the way we work, taking services effectively to scale without ever compromising our commitment to quality or our clients.

Scaling-Up Excellence is based around three interconnected pillars of Scale & Impact, Quality and Sustainability, providing a clear framework for how we can leverage our client centred approach to deliver a game changing level of impact. It demands that we keep a firm eye on operational efficiency, because every dollar saved is a dollar that could be spent on providing services to another woman in need.

Our strategy also challenges us to fundamentally shift our thinking on sustainability. We have committed to our clients that we are here for the long term. To do this we need to leverage available donor and domestic financing to deliver high-quality services. We will also use our influence to shape markets, finding the right private sector solutions that will enable women and national governments to directly pay for core services.

To be truly sustainable, we must ensure that access to contraception and safe abortion is affordable for women and national governments in 2016, 2020, 2030 and beyond.

WE COMMIT TO:

Doubling our health impact through contraception and safe abortion service delivery at scale.

— We will continue to extend our services to high impact clients including adolescents aged 15-19 years and the poor.

— We will provide contraception to 12 million additional users by 2020, 10% of the global FP2020 commitment.

— We will double our provision of safe medical abortion (MA) and medical post abortion care (MPAC), and increase post-abortion family planning (PAFP) to 90% for all safe abortion/PAC clients.

Delivering more with less by increasing provider productivity and scaling-up proven private sector cost-effective models for long acting and permanent methods (LAPM) and safe abortion/PAC. We will make universal access to contraception an affordable choice for women, couples, national governments and donors.

Setting the clinical, programmatic, and client care standards that other providers aspire to and embedding our services as the preferred choice for women.

Using our expertise as a social business to build sustainable private sector models that go beyond donor support by ensuring that every service has a funding source. Our aim is that no woman who has been given access to contraception or safe abortion will ever be denied it again.

WHAT WILL SUCCESS LOOK LIKE

By 2020 we will dramatically increase the number of services that we provide. By making choices about where we focus our
time and resources, and consistently putting the client first, between 2016-2020 our services will:– Prevent 58 million unintended pregnancies– Avert 34 million unsafe abortions– Avert 118,900 maternal deaths– Save families and governments more than £2.21 billion in health care expenses

JOIN OUR MISSION

We know the road ahead won’t be easy, but we remain committed to pursuing our vision of a world where every birth is wanted. The economic and social impacts of getting contraception and safe abortion to every woman who wants them worldwide would be tremendous. The individual benefits to current and future generations of individual women are inescapable.

At Marie Stopes International, we will do whatever it takes to achieve our mission, but we need others to join us: team members, government and sector partners, healthcare professionals, and of course organisations and individuals with the funding to make it happen.

We know the need for our services is increasing year on year, and that millions of women are depending on us to push further and faster than ever before. We will do it. We can’t fail them. Please join us.

Marie Stopes International wishes to thank those who support our work around the world. Through the gifts, grants, funding and technical assistance we receive from foundations, institutions and national governments – and the incredibly generous support of many individual givers, worldwide – we are able to serve women across the globe, including
those most underserved.